Question

question 12

dr. howitzer sees mrs. jones in clinic eight for sudden loss of consciousness while watching the olympic torch go by. he is a neurology department. dr. drake rinaldi, a prominent member of the neurology faculty at the university saw mrs. jones last m performs a medically appropriate history and exam. medical decision making is of high complexity. the final diagnosis given is consciousness. the patient makes a follow-up appointment to see dr. rinaldi in one week. what is the appropriate diagnosis a visit?

99215, r55
99203, r55
99202, r40.1
99214, r40.1

Explanation:

Determine patient status (New vs. Established)

An established patient is one who has received professional services from the physician, or another physician of the same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

• Dr. Howitzer and Dr. Rinaldi are both members of the same neurology department/faculty.
• Dr. Rinaldi saw Mrs. Jones last month.
• Therefore, Mrs. Jones is an established patient for this group practice/specialty.

Determine the appropriate E/M code

For an established outpatient office visit (CPT code range 99211–99215):

• The documentation states: "Medical decision making is of high complexity."
• Under CPT guidelines, established patient office visits require meeting the level of Medical Decision Making (MDM) or total time.
• High complexity MDM maps directly to CPT code 99215.

Determine the appropriate ICD-10-CM diagnosis code

• The patient presented with "sudden loss of consciousness."
• The final diagnosis given is "syncope" (loss of consciousness).
• The ICD-10-CM code for syncope and collapse is R55.
• (R40.1 is the code for somnolence, which does not represent syncope/loss of consciousness).

Answer:

• (A) 99215, R55 (Correct answer)
• (B) 99203, R55
• (C) 99202, R40.1
• (D) 99214, R40.1